The Apicoectomy / Periradicular Surgery Notes Template
Nosht
Published by Nosht Limited
Apicoectomy notes need to record more risk discussion than any other endodontic procedure — IAN paraesthesia, sinus communication, root fracture all warrant explicit Montgomery consent. Below is a template for UK clinicians/specialists to paste into their PMS.
Why this apicoectomy (periradicular surgery) template wins
- CBCT justification recorded — IRR 2017 ALARP compliance for the higher-dose modality.
- IAN/sinus proximity assessment per tooth — Montgomery defence for the specific anatomical risk.
- Written consent specifically referenced — for invasive surgical procedures, written consent is best practice and increasingly indemnity-required.
- Tissue sent for histology line — defensible if a cyst or atypia is later discovered.
- Root-end filling lot number — MDR + endodontic traceability.
The template (paste into your PMS notes field)
Paste the apicoectomy (periradicular surgery) template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.
TOOTH: [FDI] INDICATION: [Failed RCT with persistent periapical pathology / inaccessible root canal / iatrogenic perforation / cyst removal] PRE-OP ASSESSMENT: - Existing RCT: [Date / quality of obturation / coronal restoration status] - Previous re-treatment attempted: [Y/N — outcome] - Pre-op imaging: [PA / OPG / CBCT if indicated — IAN distance / sinus proximity / lesion dimensions] - CBCT justification (if taken): [Beyond 2D scope — neurovascular proximity / 3D lesion architecture] - MHx: [Anticoagulants / bisphosphonates (MRONJ risk) / immunosuppression / bleeding disorder] CONSENT (Montgomery): Risks discussed in detail — - Common: post-op pain, swelling, bruising - Uncommon: dry socket-equivalent, persistent infection, sinus communication (upper posterior) - Rare but serious: IAN/mental/lingual nerve paraesthesia (specify likelihood based on CBCT distance), root fracture, displacement of root-end into sinus Benefits: retain tooth, resolve persistent infection. Alternative: extraction + implant/bridge, re-treatment if not yet tried, no Tx (chronic infection). WRITTEN CONSENT signed and dated. LA: [Agent + volume + haemostatic adjunct (e.g. lidocaine + adrenaline 1:80,000 for bone surgery vasoconstriction)]. Profound anaesthesia. SURGICAL PROCEDURE: - Incision: [Sulcular + relieving / submarginal / Ochsenbein-Luebke] - Flap: [Full thickness mucoperiosteal / split thickness] - Reflection: [Atraumatic — periosteal elevator] - Osteotomy: [Round diamond / piezo — size mm / location relative to apex] - Root-end resection: [Length removed: 3mm typical / angle: 0° per modern protocol] - Curettage: [Granulation tissue removed and sent for histology Y/N] RETROGRADE CAVITY: [Ultrasonic tip / depth 3mm / aligned with canal] ROOT-END FILLING: - Material: [MTA / bioceramic (BC RRM) / IRM as historic] - Brand: [Specify] - Lot number: [Recorded] IRRIGATION + HAEMOSTASIS: [Saline irrigation / haemostatic agent — adrenaline, ferric sulfate, collagen — if used] CLOSURE: [Suture material — Vicryl 5-0 / nylon / silk / number of sutures / sites] POST-OP RADIOGRAPH: [PA taken — quality A/N — confirms retrograde filling position and coronal seal preservation] PRESCRIPTIONS: [Analgesia / antibiotic — clinical indication recorded (typically NOT indicated unless immunosuppressed or significant tissue loss)] POST-OP INSTRUCTIONS (verbal + written): Apply ice intermittently 24h. Avoid pressure / smoking / alcohol 48h. Soft diet. Maintain oral hygiene gently with CHX 0.2% mouthwash if available. Contact urgently if uncontrolled bleeding, severe swelling, persistent paraesthesia. REVIEW: Suture removal at 7 days. Clinical + radiographic review at 6 months, 1 year.
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What good looks like — a worked example
The same apicoectomy (periradicular surgery) template, completed for a realistic case.
TOOTH: UR1 INDICATION: Failed previous RCT (5 years ago) with persistent periapical pathology and labial sinus tract that re-opened despite re-treatment 18 months ago. Patient prefers to retain tooth (anterior aesthetic implication). PRE-OP ASSESSMENT: - Existing RCT: 5yr ago. Re-treatment 18mo ago. Crown placed post-re-treatment. Coronal seal intact clinically. - Previous re-treatment attempted: Yes — 18 months ago by self. Sinus tract initially resolved then recurred. - Pre-op imaging: PA + CBCT taken. CBCT shows ~6mm periapical lesion, root apex 2mm from cortical plate, no IAN involvement (anterior maxillary), no sinus communication risk (above incisive foramen). - CBCT justification: Beyond 2D scope to assess lesion dimensions, root anatomy, and proximity to anatomical structures before surgical intervention. ALARP (IR(ME)R 2017) — CBCT justified. - MHx: Fit and well. No anticoagulants. No bisphosphonates. No bleeding disorder. CONSENT (Montgomery): Risks discussed in detail — - Common: post-op pain (typically peaks 24-48h), swelling, bruising - Uncommon: persistent infection requiring extraction, fistula failure to heal - Rare: root fracture during retrograde prep, scar formation in anterior aesthetic zone Note: IAN/mental/lingual paraesthesia not applicable (anterior maxillary). Sinus communication not applicable (above incisive foramen). Benefits: retain UR1, resolve persistent infection, preserve aesthetics. Alternative: extraction + immediate implant (more complex, longer Tx, similar long-term outcome), continued chronic infection (not acceptable). WRITTEN CONSENT signed and dated. LA: Lidocaine 2% w/ adrenaline 1:80,000, 2 cartridges (3.4ml) — buccal infiltration UR2-UR1-UR1 area + nasopalatine for palatal anaesthesia. Profound anaesthesia + good haemostasis from vasoconstrictor. SURGICAL PROCEDURE: - Incision: Sulcular UR1 + relieving incision distal to UR1, blade #15 - Flap: Full thickness mucoperiosteal - Reflection: Periosteal elevator, atraumatic - Osteotomy: Round diamond bur (#4) — 4mm diameter, located 3mm apical to anticipated apex position based on CBCT - Root-end resection: 3mm removed, 0° bevel (perpendicular to long axis) - Curettage: Granulation tissue removed completely. Tissue sent for histology to exclude cyst/atypia. RETROGRADE CAVITY: Ultrasonic tip (Acteon Newtron P5), 3mm depth aligned with canal. ROOT-END FILLING: - Material: Bioceramic Root Repair Material (BC RRM Putty) - Brand: Brasseler Endosequence BC RRM - Lot number: [BC-2026-03-7890] IRRIGATION + HAEMOSTASIS: Saline irrigation. Ferric sulfate 15% in osteotomy briefly for haemostasis (rinsed thoroughly). CLOSURE: Vicryl 5-0, 4 sutures — 2 along sulcular incision, 2 closing relieving incision. POST-OP RADIOGRAPH: PA UR1 — BC RRM clearly visible at retrograde site, root-end filling in good position, coronal seal preserved. Quality A. PRESCRIPTIONS: Analgesia — ibuprofen 400mg / paracetamol 1g PRN, alternate. NO antibiotic — patient immunocompetent, no significant tissue loss, minimal contamination risk. POST-OP INSTRUCTIONS (verbal + written): Apply ice intermittently 24h. Avoid pressure on lip / smoking / alcohol 48h. Soft diet. CHX 0.2% mouthwash from 24h (rinse only, do not swish vigorously). Contact urgently if uncontrolled bleeding, severe swelling, persistent paraesthesia (rare in this case). REVIEW: Suture removal at 7 days. Clinical + radiographic review at 6 months + 1 year + 2 years.
Compliance: the medico-legal angle
- RCS England FDS Guidelines for Periradicular Surgery (2020) — current UK guidance for the procedure.
- BES Guide to Good Endodontic Practice 2022 — surgical endodontic standards.
- IR(ME)R 2017 — CBCT requires explicit justification beyond 2D alternatives.
- Montgomery — surgical procedures with material nerve risk demand detailed risk-specific consent.
- MDR 2017 — root-end filling material is a regulated medical device; lot number traceability required.
Common documentation mistakes
- CBCT taken without documented justification for dose vs 2D — IR(ME)R breach.
- No specific paraesthesia risk discussion for lower posterior teeth — Montgomery breach.
- Tissue not sent for histology when curettage of soft tissue lesion was performed — leaves no defence if subsequent malignancy diagnosed.
- Antibiotic prescribed routinely post-surgical endo — most cases don't need it; over-prescription is the audit issue.
- No long-term radiographic review scheduled — 1-year and 2-year radiographic healing assessment is the standard.
Sources
- The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)
- Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
- SDCEP: Oral Health Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw (March 2017) (accessed 18 October 2026)
- British Endodontic Society: A Guide to Good Endodontic Practice (1st edition, September 2022) (accessed 18 October 2026)
Frequently asked questions
When is apicoectomy indicated over RCT re-treatment?
When orthograde re-treatment is impossible (e.g. post that can't be removed, transportation, perforation) or has failed. Apicoectomy success after failed re-treatment ~60-70%. Most modern endodontists try re-treatment first if technically feasible — apicoectomy is the second-line option.
When do I need CBCT before apicoectomy?
When 2D imaging doesn't adequately show: root anatomy (curvature, accessory canals), lesion dimensions, neurovascular proximity (IAN, sinus, mental foramen). For most posterior teeth with significant lesions, CBCT is justified. IR(ME)R 2017 requires justification and doses kept as low as reasonably practicable (ALARP): document why 2D is insufficient.
MTA, bioceramic, or IRM for root-end filling?
MTA and bioceramics (Biodentine, BC RRM) are evidence-based first-line. IRM (zinc oxide eugenol) is historic — still acceptable but bioceramic outperforms in healing studies. Document material and lot number.
How much root-end do I resect?
Modern protocol: 3mm. Older textbooks said 2-3mm with 45° bevel — modern evidence favours 3mm with 0° bevel (perpendicular to long axis) to minimise apical accessory canals left behind.
Do I prescribe antibiotics post-apicoectomy?
Not routinely. SDCEP guidance: antibiotics only when systemic signs, immunocompromised, or significant tissue loss. Most uncomplicated apicoectomies in healthy patients don't need them. Document the rationale either way.
How do I assess success?
Clinical: symptom resolution, sinus tract closure, no tenderness. Radiographic: periapical bone fill on follow-up PA/CBCT at 6, 12, 24 months. Modified Molven criteria — complete / incomplete / uncertain / failure. Document at each review.
Patient leaflets for this treatment
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Nosht
Published by Nosht Limited
Nosht Limited makes structured clinical note templates for UK dental professionals. Articles refer to guidance from the GDC, CGDent, BSP, SDCEP and NICE. Check the current version of a source before relying on it.